Nephrostomy Treatment & Management

An evaluation for nephrostomy can be conducted on an outpatient basis if the patient's medical condition permits. Inpatient studies and surgical treatment may be necessary in emergencies or in unstable patients.

• Medications

  • Most patients should receive broad-spectrum parenteral antibiotics.
  • If drugs are administered, the authors recommend cephalosporin or a combination of penicillin and aminoglycoside prior to the procedure, depending on the patient's allergies.
  • In pediatric patients, adjust antibiotics for age and weight.
  • Drug contraindications include corresponding drug allergies and urinary tract infection in an elective setting, hepatic failure, and renal failure.
• Pregnancy: During pregnancy, nephrostomy is limited to only selected individuals, such as those with symptomatic renal obstruction and an inability to access the kidney from the bladder.
• Consultations

  • Nephrologist, for possible dialysis
  • Oncologist, for prognosis and survival of patients with oncologic causes for urinary tract obstruction
  • Surgeon and gynecologist for urinary tract obstruction due to disorders in their respective fields

Depending on the hospital situation, the nephrostomy can be placed under ultrasound guidance or direct fluoroscopy either by a urologist or a radiologist.

• No special diet is required if surgery is performed under local anesthesia.
• The procedure can be performed under fluoroscopic or ultrasonographic guidance. A CT-guided nephrostomy or placement during open surgery is possible but only rarely used.
• Perform the procedure in the operating room, the fluoroscopy suite, or the ultrasound room.
• Use lead glasses, a thyroid shield, and a lead apron when overhead radiography is used. Limit fluoroscopy time and cone down the radiation field.
• Several ultrasound transducers can be used (eg, 7.5-MHz transducers). Ultrasound has become the preferred guidance modality in the placement of a percutaneous nephrostomy. Opacifying the renal collecting system with intravenous or retrograde injection of iodinated contrast was once necessary to allow fluoroscopic visualization. The use of ultrasound reduces both the amount of radiation and the possible complications of intravenous administration. Furthermore, real-time multidimensional imaging reduces procedure time, allows visualization of adjacent structures, and reduces the possibility of iatrogenic trauma. Following placement of the nephrostomy needle, the procedure can be completed under ultrasonographic guidance; more commonly, the collecting system is opacified directly, and the procedure is completed under fluoroscopy.
• Even if the kidney has limited hydronephrosis and still needs nephrostomy, ultrasonography can be used to identify the renal collecting system.
• Proper selection of the appropriate calyx is vital in nephrostomy tube placement to allow access to various parts of the kidney. If the tube is placed too low, the ureter may be difficult to access; the ureter is easier to reach from an upper-pole calyx.
• Failed access is occasionally a problem. When nephrostomy placement is not an emergency situation, wait a few hours (or even days) until the dilatation of the renal collecting system has increased to facilitate the puncturing of the collecting system.
• The nephrostomy tract usually matures within a few weeks; therefore, the nephrostomy remains open for hours to days after the tube is removed following maturation. Whenever a tube is removed after a long period, place a pressure dressing to cover the skin and tract defect.

• Always obtain adequate visualization of the calices.
• Identify a posterior calyx for puncture that (1) provides access to the appropriate segment of the kidney for anticipated procedures and that (2) allows safe creation of a tract.
• Puncture the collecting system of the kidney with a needle below the 11th rib and, preferably, below the 12th rib, when feasible.
• Puncture the tip of a posterior calyx from a 20-30° posterior oblique approach to avoid major blood vessels (eg, renal vein, renal artery).
• The nephrostomy can be placed through any posterior calyx within the kidney.
• A lower-pole calyx is often selected for drainage because it is usually infracostal, thereby precluding a pneumothorax/hydrothorax complication, anatomy shown below. Positioning of nephrostomy tube into the lower pole of the kidney.
• A supracostal puncture of the middle or upper portion of the kidney may be needed for stone or tumor removal.
• Use 5 mL of lidocaine (1%) for local anesthesia.
• Fluoroscopic guidance can be used for access, but some urologists and radiologists prefer ultrasonographic guidance (eg, with a 3-MHz or 5-MHz curvilinear transducer), especially until the nephrostomy needle passes into the collecting system.
• After entering the collecting system, withdraw the obturator of the needle. If urine flow is present, use 3-5 mL of contrast to check for proper placement.
• Advance a guidewire (eg, 0.035 in) into the collecting system.
• Remove the needle with the guidewire in place.
• Use a fascial incising needle or scalpel to cut the lumbodorsal fascia.
• The tract can be dilated with a plastic fascial dilating catheter passed over the guidewire (6F, 8F, and 10F catheters). Further dilation of the tract may be necessary if a percutaneous nephrolithotomy is planned.^{[4, 5]}
• A nephrostomy catheter (8-14F) can be placed over the guidewire; affix it to the skin with a suture or plastic retainer.

  • The catheter size depends on the intended purpose of the nephrostomy. Simple urine drainage can be achieved with an 8F catheter. If the collecting system is punctured for further procedures in the kidney (eg, tumor or stone removal), a larger catheter must be used (14-22F).
  • Smaller tubes have some advantages and disadvantages compared with larger tubes. The smaller tubes cause less trauma and are easier to insert; however, they do not drain the kidney as well as the larger tubes and are less effective in compressing the tract. The larger tubes cause more trauma and are slightly more difficult to insert but offer better drainage of the kidney and compression of the tract.
  • As for catheter selection, Malecot-type catheters require a skin suture, while balloon catheters do not. Renal pelvis–dwelling catheters are more secure than nephro-stent–type tubes.^[6]
• The guidewire can be removed after the nephrostomy catheter has been checked fluoroscopically. If the tube leaks after placement, a larger tube may be used. However, most leakage resolves within a few hours. If the tube falls out, it can usually be replaced through the same tract (if the tract is matured). For freshly placed tubes, a new kidney puncture may be necessary.
• Use a pigtail with a lock; most nephrostomy catheters have a locking mechanism to prevent displacement.
• As indicated, send the aspirate from a kidney urine specimen for culture.
• Bleeding during nephrostomy placement may be enough to terminate the procedure; however, clamping the tube for 30-40 minutes and administering intravenous diuretics stops most venous bleeding. For arterial bleeding, perform angiography and consider embolization of the bleeding vessel.
• To preclude kinking, smoothly drape the tube as it exits the skin over a roll of gauze.
• Connect the nephrostomy catheter to a urine bag that can be strapped to the leg.

After nephrostomy tube placement, most patients have bloody urine for several hours; this bleeding usually resolves spontaneously. The nephrostomy tube can be irrigated gently with 5 mL of sodium chloride 0.9%. Clots can be removed from the nephrostomy catheter. Observe for fever if the urine appears cloudy. If the hematuria does not resolve spontaneously, troubleshoot the nephrostomy as follows:

• If bleeding occurs from around the nephrostomy tube, an additional skin suture may resolve the bleeding.
• If bleeding occurs inside the nephrostomy tube, check the bleeding time and CBC count; then, consider arteriography and possible segmental embolization of the kidney in the interventional radiology department.

Postobstructive diuresis can occur with polyuria (for management, refer to eMedicine articles Chronic Renal Failure and Acute Renal Failure). Regularly check blood pressure, blood count, and urine until they become stable. Conditions vary according to individual circumstances.

• Further inpatient care may require testing and surgical intervention, which may include nephrolithotomy or reconstructive surgery.
• Most patients can be discharged home the day of the procedure. Outpatient instructions focus on nephrostomy tube care (eg, change dressing daily, keep dressing dry and clean when showering, avoid submersion).
• Patients should avoid strenuous activity and sports until the nephrostomy tube is removed.

Inpatient and/or outpatient medications

• Prophylaxis with suppressive antibiotics is not recommended.
• Medications include antibiotics (eg, cephalosporin in cases of urinary tract infections) until infection is treated.
• Carefully monitor medication dose and adverse effects and treat infections only when symptomatic.

Common complications

• Perforation of the collecting system (< 30%) typically resolves within 48 hours of nephrostomy tube placement, provided that drainage of the collecting system is established (via nephrostomy tube or ureteral catheter).
• Possible complications of the intercostal approach include pleural effusion, hydrothorax, and pneumothorax, possibly requiring chest tube placement (< 13%).
• Acute bleeding requiring transfusion (< 5%): Bleeding through the nephrostomy tube may require clamping the tube for 30 minutes to 2 hours and subsequent irrigation of the tube with sodium chloride 0.9% after enforced diuresis.
• Failed access (< 5%): Reattempt access after the dilatation of the collecting system has increased in the course of hours or days.

Rare complications

• Periorgan injury, including bowel perforation, splenic injury, and liver injury (< 1%): Extraperitoneal colon injury and duodenal injury can be managed conservatively with stenting of the urinary system and using the percutaneous tube as an enterostomy tube for 48 hours. Afterward, remove the enterostomy.
• Intraperitoneal injury that mandates open exploration (< 1%)
• Infection leading to septicemia (< 1%)
• Significant loss of functioning renal tissue (< 1%)
• Delayed hemorrhage (< 0.5%): The authors recommend that patients in whom the nephrostomy is doubtful or difficult are kept overnight.
• Emergency arterial embolization of the kidney (< 0.5%) with uncontrollable arterial bleeding: Clamping the nephrostomy tube for a few hours stops most venous bleeding.
• Administration of antihistamines and steroids and use of nonionic or low-osmolar contrast media in cases of known allergic contrast reaction (< 0.2%)
• Nephrectomy (< 0.2%)
• Mortality (< 0.05%)

Patients with uncontrolled hypertension may develop perirenal hematoma or extensive renal hemorrhage. Use all efforts to control blood pressure.

Medicolegal Pitfalls

• Failure to obtain informed consent on the indications and complications
• Removal of the nephrostomy tube

  • Fluoroscopic guidance may be necessary, especially to ensure proper drainage of urine through the ureter into the bladder prior to nephrostomy removal.
  • A thorough inspection of the catheter is necessary to ensure complete removal.
  • Retained fragments of a catheter predispose the patient to infection and calculi formation.

Acknowledgment

The authors thank E. Russel, MD, and H. Huson, MD, from the Department of Radiology and J. Posey, MD, from the Department of Urology of the University of Miami for their help.